STRATEGIC OVERVIEW OF INDIAN HEALTH CARE SETTING

WHAT CONSTITUTES HEALTH CARE INSTITUTION? Apart from Hospitals, there are many other health care related institutions like Wellness centres, Health Spa, Hospices, Poly Clinics, Para Medical institutions, Old Age Homes, Palliative care centres etc. The institutions are basically divided as Government v/s Non Government, For Profit v/s Not For Profit, Primary v/s Secondary v/s Tertiary

NON-PRIORITY FUNDING BY GOVERNMENT Over the years the government budgets globally have reduced their spending on healthcare. There has been a concerted effort to privatize the healthcare business at all levels. In India the percentage GDP spend on healthcare has been declining on a per annum basis. The government expenditure has been more on building infrastructure like roads, ports, telecommunication, power etc and less on social sector essentials like education and health care.

TIER SYSTEM The health care institutions are generally planned into a TIER system which starts with the Primary Level healthcare wherein the basic facility of outpatient based medical care is combined with limited general surgical set up. Secondary care centres provide services in all medical and surgical faculties and has more in patient based facilities. These centres include advanced diagnostics and critical care facilities with a capability to treat most diseased conditions. The Tertiary care centres provide all the facilities in a secondary care centre and also some super specialty services in areas like Cardiac Surgery, Neuro Surgery, Urology, and Orthopaedics. The tier systems helps a planner to identify the infrastructural needs of the building to be planned.

POPULATION DISTRIBUTION India been a vast country with agrarian economy, the population distribution continues to be rural based. The healthcare infrastructure has more bias towards the developed cities with secondary and tertiary care centres, whereas the rural belt is left stranded with only the primary care set ups. The referral system been under developed, the rural masses have very little choice of treatment for advanced diseases.

Hospital Planning

Dr. Vivek Desai

AWARENESS PROBLEM AMONGST USERS Low levels of literacy combined with negligible media coverage has not helped the healthcare industry in expanding its market base. It only offlate with the advent of health insurance and promotion of privatized healthcare, that the media coverage of health care has improved thereby making the population aware of various issues involved in the delivery system. This trend will only continue as is evident with the increase on number of publications targeting the health care markets.

LACK OF PROPER REGULATION As compared to any other organized sector, healthcare sector is plagued with the problem of complete lack of regulation. There is no set standard guideline to plan and operate a health care facility. Various attempts made towards developing a standardized document by non governmental organizations and the government has not been properly channelized. Regulations would be required for minimum standards for physical infrastructure as well as for operational procedures like manpower skills/record keeping. Certain institutions like ICRA and CRISIL have already formed Accreditation norms and have started rating hospitals. Even the Health Insurance companies have started to emphasize on the concept of minimum standards for recognizing hospitals in their network.

TECHNOLOGICALLY UNDERDEVELOPED The healthcare organizations in India are as yet not keeping pace with the technological advances in medical devices and IT. Only the tertiary care hospitals in bigger cities have recognized the importance of such technology and have opted for the latest equipment. The major problem in this is most advanced technology has to be imported which increase the cost of acquisition. Primary and secondary level instituitions should opt for more indigenous technology, wherein the cost could be curtailed and servicing also becomes easier.

FINANCING OF HEALTH CARE INSTITUTIONS Financing mechanisms for setting up hospitals is also under developed. Though the lending rates for capital has reduced from the 15% to around 10%, it still will need to go further down. The recent budget in 2003 has given a welcome break for hospitals above 100 beds, wherein the lending institution will get tax benefit on the interest thereby reducing the lending rate by almost 2%. Such sops will definitely help brining more entrepreneurs in the fold, especially the medical fraternity. Customs duty rationalizations still remains a distant dream, which if done will bring big relief to the hospital owners.

Hospital Planning

Dr. Vivek Desai

PURCHASING POWER OF THE CONSUMER Over the years the purchase power of Indian consumer has witnessed a upward growth, but still health care expenses remain one of the highest cost of debt especially in semi urban areas. The fast growth of health insurance will definitely help in brining in more people into the fold who can afford institutionalized health care. Corporates have also been a big contributor to the health care industry wherein most specialized care is been reimbursed for their employees as medical benefit perquisite.

INFRASTRUCTURE PROBLEMS (UTILITIES, ROADS ETC.) As in all other industrial growth in any country, infrastructure problems related to basic amenities like access roads, electricity, water, drainage, and telecommunications remain a major problem area for the hospitals. This deficiency is more pronounced in non urban areas and even in big cities like Chennai, Bangalore, Calcutta etc. Such deficiency result in high cost of such infrastructure as one has to rely on their own capacities of generators, water treatment plants etc, which ultimately increases the cost of the project.

Hospital Planning

Dr. Vivek Desai

STAKEHOLDERS IN HEALTH CARE INDUSTRY

Health care sector is one of the few industry which have diverse stakeholders ranging as under: OWNERS GOVERNMENT (Central, State, District, and Local Bodies) NOT FOR PROFIT HOSPITALS (Mostly owned by charitable Trusts, societies, and multilateral agencies) FOR PROFIT HOSPITALS (Corporate Hospitals)

CONSUMERS (PATIENTS/RELATIVES, 3RD PARTY PAYERS) PROFESSIONALS (Doctors, Nurses, Para Medical staff, Managerial, IT professionals, bio-medical engineering, finance etc) EQUIPMENT (Medical & Non Medical) AND OTHER VENDORS PHARMACEUTICAL COMPANIES FUNDING AGENCIES (Financial Institutions & Insurance) ARCHITECTS CONTRACTORS (civil, electrical, air-conditioning, plumbing, fire fighting, interior design, data cabling, building maintenance etc.) ENGINEERS (consulting as well as contracting)

In view of the above, it is evident that the industry has a very diverse portfolio of stakeholders and hence affects a large cross section of professionals and businesses. Thus proper growth of the sector will create more employment opportunities for a large cross section of population.

Hospital Planning

Dr. Vivek Desai

STEPS IN HOSPITAL PLANNING

Any hospital project has five basic steps that one needs to follow: 1. 2. 3. 4. 5. Project Conceptualization Detailed Feasibility Study Architectural and Engineering Services Design Project Management Commissioning of the Hospital

1. PROJECT CONCEPTUALISATION This is perhaps the most important step as it sets the tone for all future work for any hospital project. This perhaps is also the most difficult step as the promoters have many ideas for the project and needs proper filtering of various options to arrive at a Hospital Concept. This has major implications on the planning process as well as on the cost of the project. PROMOTERS IDEA/PHILOSOPHY MARKET RESEARCH FIRMING UP OF THE CONCEPT 2. FEASIBILITY STUDY TECHNICAL DETAILS COMMERCIALS MEANS OF FINANCE 3. ARCHITECTURAL DESIGNING CONCEPTUAL DESIGNS FUNCTIONAL SPACE PLANNING WORKING DRAWINGS 4. PROJECT MANAGEMENT CO-ORDINATION AMONGST VARIOUS AGENCIES FINANCIAL BUDGETING DRAWING UP THE EQUIPMENT PLAN PERT-CPM TECHNIQUES 5. COMMISSIONING THE SERVICES EQUIPMENT PURCHASE & INSTALLATION RECRUITMENT SYSTEMS, POLICIES, PROCEDURES TARIFF DESIGNING

Hospital Planning

Dr. Vivek Desai

STEP 1 PROJECT CONCEPTUALIZATION

PROMOTERS VIEWPOINT
INDIVIDUAL/TRUST/CORPORATE/GOVERNMENT PHILOSOPHY THRUST AREAS PROPOSED BUDGETARY ALLOCATION

MARKET RESEARCH
RAPID ASSESSMENT V/s DETAILED SURVEY PRIMARY DATA V/s SECONDARY DATA HOUSEHOLD SURVEY SAMPLING HOUSEHOLD COMPOSITION & DEMOGRPAHIC DETAILS INCOME DETAILS SICKNESS DETAILS IN LAST ONE YEAR CIRTEIRA FOR CHOOSING HEALTH CARE FACILITY REPONSE TO CLIENTS CONCEPT OF HOSPITAL

INSTITUTIONAL SURVEY FACILITY MIX PRODUCTIVITY DETAILS TARIFF DESIGN STRENGTHS/WEAKNESSES DOCTORS SURVEY SAMPLE SELECTION OPINION ON HEALTH CARE DELIVERY SYSTEM PATIENT PROFILES & ATTITUDE FOR PAYING FACILITIES THAT SHOULD BE DEVELOPED SUCCESS CRITERIA FOR THE PROPOSED FACILITY

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PROJECT CONCEPTUALIZED
FINALIZATION OF FACILITY MIX WITH PHASING IF ANY BED MIX (DELUXE, SINGLE, DOUBLE, GENERAL, ICU) IDENTIFICATION OF LOCATION BROAD MILESTONES FIXED TENTATIVE BUDGET PROPOSED GO AHEAD GIVEN FOR FEASIBILITY STUDY

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FEASIBILITY STUDY
PART A TECHNICAL DETAILS

SPACE PLAN

- DEPT. WISE FUNCTIONAL SPACE PROGRAM

FLOORWISE AREAS PRIMARY/SECONDARY AREAS SCOPE FOR EXPANSION

EQUIPMENT LISTING WITH PRICES

MEDICAL NON-MEDICAL FURNITURE AND FIXTURES LIFTS

MANPOWER PLANNING
SHIFTWISE SKILLS WISE BUDGET FOR LEAVE/ABSENTEEISM

UTILITY REQUIREMENTS AND THEIR COST

ELECTRICAL AIR-CONDITIONING (ENERGY SOURCE) WATER PLUMBING/DRAINAGE WASTE MANAGEMENT

Hospital Planning

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PART B FINANCIAL FEASIBILITY

1. PROJECT COST

LAND & BUILDING

COST OF LAND & LANDSCAPING V/S LEASE OPTION (BOOT STRATEGY OF IL&FS) AREA IN SQ FT X COST PER SQ FT (split up as cost of superstructure, faade, & interior work) HVAC Chillers, cooling towers, piping, ducting, insulation, AHU, grilles, electrical panels etc ELECTRICAL HT, LT, Generators, cabling, wiring, panels, distribution boards, fixtures, data cabling, telecom, fire detection, CCTV, nurse call systems, etc PLUMBING water storage, pumps, water treatment, sewage treatment, boilers, fire fighting, fixtures, piping, reverse osmosis etc ELEVATORS LANDSCAPING ARCHITECTS & OTHER FEE CONTINGENCY @ 5-10%

MEDICAL EQUIPMENT DEPTWISE BREAK UP WITH INDEGENOUS or

IMPORTED, CURRENCY/INR, CUSTOMS DUTY ETC.

NON MEDICAL EQUIPMENT HVAC, CSSD, COMMUNICATION, LIFTS, DG-SET, INCINERATOR FURNITURE & FIXTURES PATIENT RELATED OFFICE

COMPUTERS,

PREOPERATIVE COSTS (legal, stamp duty, consultants etc.)

INTEREST DURING CONSTRUCTION

WORKING CAPITAL (AT LEAST THREE MONTHS)

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2. INCOME PROJECTIONS
ROOM RENTS CLASSWISE, PROVIDE FOR CHARITY

DEPARTMENTAL INCOME

ASSUMPTIONS DEPTWISE & SEPARATE FOR OPD/IP, CAPACITY UTILISATION CHARITY (EXCLUDING PHARMACY/EHS) DOCTORS FEE SEPARATE IT OUT FROM OT CHARGES MISCLLANEOUS INCOME CANTEEN, PASSES, AMBULANCES

3.

EXPENDITURE PROJECTIONS
SALARIES & WAGES (GROSS COST TO COMPANY METHOD AND KEEP 10% AS PERKS) CONSUMABLES PEG IT AS % OF INCOME OF DEPT. UTILITIES GASES, WATER, POWER LAUNDRY & LINEN FOOD HOUSEKEEPING PRINTING & STATIONARY COMMUNICATION TRAVL & CONVEYANCE DEPRECIATION REPAIRS & MAINTENANCE INSURANCE & AUDIT LOAN SCHEDULE (IF APPLICABLE) MISCLLANEOUS TAX (IF CORPORATE)

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4. PROFIT & LOSS STATEMENT

SURPLUS/DEFICIT PROFIT/LOSS DIVIDEND (IF CORPORATE)

5. BALANCE SHEET DERIVATION 6. BREAK EVEN ANALYSIS (cash/book loss)

7.

SENSITIVITY ANALYSIS
PROJECT COST ESCALATION BY ----% LESS CAPACITY UTILISATION RECURRENT EXPENDITURE CHANGE DEBT : EQUITY RATIOS (LIBOR/INR LOANS, FLEXIINTEREST)

ARRIVE AT MEANS OF FINANCE & ITS STRUCTURING

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ARCHITECTURAL DESIGN
HISTORY OF HOSPITAL ARCHITECTURE

SELECTION OF ARCHITECT
Previous experience health care/hotel Indian/western design concepts Inhouse capabilities cad/jr.arch/str. Engg./HVAC/electrical/plumbing consultants Flexible approach

SITE SELECTION
Site contours for shape of bldg Accessibility Soil testing Foot print of building & fsi Availability of utilities in proximity Parking areas

PREPARATION OF ARCHITECTS BRIEF

Space allocation Traffic flows and peak loads Functional intricacies of departments Location of services Sterility requirements Technical requirements clinical ot, icu,lab, casualty, wards, ct-scan, cathlab, support-laundry, kitchen, cssd Specific civil requirements Mention of a/c, electrical, plumbing, vertical transport requirements Possibility of expansion Residential quarters requirement Local rules

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CONCEPTUAL DESIGNING
Building shape (vertical/horizontl) Future expansion Stack plan Types of designs (refer notes) Vastu shastra Light, wind, rain beating Ventilation and air circulation Centrally air-conditioned or selective

DECIDING ON COLUMN GRID

FINALISATION OF GRID MATRIX AFTER SATISFYING ALL REQUIREMENTS

BASIS FOR ALL FUTURE DESIGN

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SCHEMATIC DESIGN:
Most important stage wherein there is lot of iterations with the client & user groups Block diagrams are converted into individual spaces Departments are broken down into smaller spaces with furniture layouts Wall Thickness, Doors, windows are shown Important engineering elements are put into proper places like basins, plug points etc At this stage the drawings are ready to be circulated between various consultants for finalizing locations of engineering services Other consultants also commence their schematic design for the engineering services By the end of this stage, we are ready for tendering the project in terms of the civil works

WORKING DRAWINGS
Details with measurements for contractors to construct the building Columns & beams details with specifications for use of raw material Equipment layout in consultation with vendors and users (doctors) Doors, windows schedule Plumbing & drainage details with type of toilet in terms of sunken slab/suspended piping Electrical details with type of points and their heights Reflected ceiling plans To be signed by architect as good for construction and stored for future use Similar Working drawings will be made by all engineering consultants for their respective systems

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INTERIOR DESIGN PROCESS:

Internal spaces have to appropriately dressed in terms of flooring, woodwork, false ceiling, painting, soft furnishing, fixed furniture etc. For this the interior designer needs to have detailed meetings with the users. Can be broadly classified as Medical & Public areas Finishing material for medical areas needs to be carefully planned as in operation theatres, laboratories, critical are units, procedure rooms, patient rooms etc The same process of concept schematic working drawings will be followed and co-ordination will need to be done with various other consultants

MASTER PLAN
Long range plans for 10-20 years Can be used by existing hospitals also Only conceptual in nature Most important criteria is to build the expansion whilst hospital is in operation (horizontal v/s vertical) Redundancy of certain engineering will need to be costed and client to take decisions

ARCHITECTURAL RE-DESIGNING
For existing hospitals Objectives should be very clear Limitations to be identified Least disruption of services Temprory relocation of services Get clearance from structural eng & other agencies to assess the feasibility May or may not blend with old structure

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PROJECT MANAGEMENT
Forming the Team:

Project Manager from promoters side or consultants/architects Architect and his site engineer Contractors civil, electrical, plumbing, HVAC, medical gases Structural eng, Electrical, Air-conditioning and plumbing consultants Promoters representatives including a site engineer, accountant Special invitees Doctors, bio-medical engineer, administrators Hospital Administrator for expansion projects

Roles for:
Structural Engineer: Studies pertaining to soil testing and advises the architect on the type of structure and foundation needed to support the building Prepares schematic structural layout and grid planning to enable the architect to proceed with detailed planning Prepares preliminary and detailed costing for columns and beams Prepared detailed construction drawings Undertakes inspection and testing, and reviews construction Scrutinizes contractors bills and certifies payments

Electrical Engineer: Study the site layout and availability of electricity in vicinity Calculate the load required and advise on location for the transformer as well as routing of cable from the supply source Prepares detailed electrical layout for the architect Prepare estimates of costs Prepare tender documents and scrutinise same for awarding the contract Undertake inspection during execution and certify bills

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Plumbing Engineer: Study the requirement and availability of water in vicinity Study method of disposal of liquid waste and the adequacy of existing sewage system in the vicinity Advise for ideal location and capacity of treatment plant, septic tank, soak pit, sump, overhead tank etc. Prepare a schematic & detailed plumbing drawing Estimate the cost in consultation with architect Design and co-ordinate the tendering process Undertake inspection and testing and certify bills for payment

Tender Document:

Notice inviting tenders Pre-Qualification process Open v/s limited tenders General and special conditions of the contract Technical specifications Bill of quantities Important - date of commencement/completion, defects liability period, certification and payment of interim bills, retention amounts, penalty clauses, variation clauses, extra items, arbitration, quality checks etc.

Selection of contractors:
1. Verify credentials 2. Do not necessarily go in for lowest tender at cost of quality 3. Call for negotiation 4. Build good rapport as the agency will be crucial for good construction and speedy execution

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Characteristics of a project:

A start and a finish A defined time frame for completion A unique one timeness An involvement of several people of varying skills on an ad-hoc basis Limited set of resources A sequencing of activities and phases

Remember:
Project Planning begins with the end in mind i.e. the goal and works backwards. Clarify what you are trying to accomplish for the client and keep it uppermost in mind. Make sure that everybody else on the project team is aimed at the same direction Goals should be SMART : Specific Measurable (milestones) Agreed upon Realistic Time-framed

For Effective Project Management Manage COST QUALITY TIME Establish Checkpoints List the Activities in proper chronology Determine Relationships between activities Make Time Estimates for each activity Create Project Schedule Timely Communicate Information to all concerned Hold Regular Meetings with Agenda & Minutes
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Financial Budgeting Deriving a realistic project cost Continuously monitoring the project cost for identifying escalation items/reasons Look for cost cutting cement/steel prices, labour cost, staggered delivery, ordering equipment at correct time Ensure liquidity of funds for making payments to various agencies Phasing out where ever essential/possible in case of liquidity problem In case of debt, timing of taking debt to reduce the start time for payback Buying material on credit

Equipment planning Prepare detailed list in consultation with doctors and other users Seek quotations from all vendors OR give advertisement Seek list of clients and cross check Look for sound credentials and ownership pattern Can we directly import from country of manufacture? Keep an eye on currency fluctuation Take help from bio-meds for doing a cost-feature analysis Call for negotiation and argue for extended maintenance contract Draw the contract carefully and insert clauses for downtime, response time, spare parts availability Be sure on post installation trial runs Look for schemes on hire-purchase, leasing, consumable deals etc.

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DEPARTMENTAL PLANNING
PATIENT HOUSING SYSTEM: Should be dealt with as the residence of patient and hence should be as close to the patients residence. The difference is that the patient would need nursing and other medical attention. It is thus necessary that the planner should know the type of nursing required in the wards, because the requirements vary with type of patient. Broadly the patients in need of care can be divided into five categories. Intensive medical care Intensive nursing care Medium nursing care Low nursing care Self care with minimal nursing care In acute care wards 4-5 hours of nursing care may be required In normal wards requiring medium nursing care one nurse may be enough for 10 beds One sister in charge should look after not more than 30-35 beds Maximum distance between the nursing station and the furtherest bed should not be more than 75 feet (govt hospitals)and in newer hospitals even not more than 30 feet

1. 2. 3. 4. 5.

The decision on patient housing system would thus depend upon the following Type of ownership and philosophy Type and level of nursing required Division by speciality/sub speciality Accommodation by sex or social-economic class What proportion of beds are to be in single room, double rooms, etc.? How many intensive care beds and assumptions on type of nursing care ? Is it to be combined ICU/ICCU/SICU or separate? Will there be grouping of certain specialities? Will there be any psychiatric beds? Is there a self care unit to be planned? Any special planning requirements besdies the standard nursing unit like doctors cabin, recreation lounge, fathers room, day room, business lounge, dining room Home Health Care concept

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Type of wards; 1. Nighting Gale Type : Open type with perpendicular arrangement of beds Nursing unit at one end and sanitary block at the other end Advantage good supervision, visual access, accommodates more beds Disadvantage noise, lack of privacy, too many patients, problem in cold countries, danger of cross infections 2. Riggs Pattern: Improvement on nighting gale type by dividing the ward in cubicles (not full walls) with 4-6 beds 3. Single Rooms (most common in US after Nuffield Foundations recommendation which stressed on possibility of infection by grouping patients) 4. Double rooms (more to improve productivity and decrease costs) 5. Patient units of 4-6 beds are more popular in Europe where 20-25% beds are single rooms

Shape of the Wards: a. Single corridor Nighting Gale Type but has drawback of long distances but is suitable for tropical countries where air-conditioning is not commonly used Double corridor patient rooms on periphery and service areas in middle - economizes the distances to be travelled - problem of ventilation and natural light in work areas - good for fully air-conditioned buildings (common in US) - best for nursing efficiency - central service should not be more than 20 feet Circular not popular because of construction difficulties and again requires provision of light in the middle - good for observability and supervision - distance to be travelled is also less X shape and Y shape

b.

c.

d.

Note: In our country because of the intense heat, the wards should face North-South with the patient rooms facing South.

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Basic requirements in Wards: * Nursing station sitting arrangement, shelves, telephone, computers, drugs, emergency trolley, wash basin, lockers, change room Toilets for patients, staff Dirty utility room/s Clean storage Pantry/dining Strecther/wheel chair bay Treatment room Other requirements day care room, meeting, prayer room, business lounge, staff rest Corridor width and door widths Height Plug points Toilet dimensions Effect of size on Occupancy

Types of Special Wards Critical care units ICU/SICU/ICCU/NICU/PICU/ITCU/Respiratory care units Burns units Neo-natal units Maternity (LDRP concept) Psychiatric Paediatric Geriatric

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OUTPATIENT DEPARTMENT Increasing importance of OPD worldwide under ambulatory services concept Ambiguity in roles of OPD and casualty should be sorted out and define the OPD/referral/emergency clearly Timings for OPD to be clearly specified Should we go in for general/private OPD model Would you like the inpatient and OPD services to be integrated? Will the OPD be an autonomous department? Work out the load projections inlcuding forecasting for growth and peak loads expected Room utilization and clinic scheduling to be defined Define the relationship with support departments like billing, pathology, radiology

Location & Space Requirements: Not necessarily on the ground floor Accessibility as per ambulatory/escorted/vertical transport availaibility Separate block for OPD and diagnostics Reception area/s central v/s individual Billing area for cash collection Nursing station (one for every 3-5 rooms) Waiting area (per person 4sft and as per projected peak load for next 10 years) Record room (localized/central) Examination Area (individual/common/speciality) Hand wash facility Changing room facility Treatment Area (common) Internal layout details as per the speciality Sample collection room Water cooler Toilets/DU

Relationship with other departments Billing Pharmacy Medical records Social Worker Pathology Radiology Other diagnostics Role of computers

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PATHOLOGY (Department of Lab Medicine) Today pathology covers a variety of sub specialities like: Biochemistry Haematology Histo-pathology Serology Microbiology Blood Bank

Its importance has increased in recent years due to the over reliance of the medical fraternity on diagnosis and preventive aspects. Consumer protection act has also lead doctors to advise for more tests to ensure correct diagnosis. The fast pace of technological advances has further made this speciality more important in hospitals and due importance has to be given for its proper planning.

Important points for planning:

Whether to have a lab or not Contracting the lab out Projects may have only laboratory (Speciality Ranbaxy) Level of sophistication that the promoters want which will give us the range of investigations to be expected Specialised services like Histo-pathology, microbiology, blood bank etc Technology that would be installed or is anticipated Projections for handling IPD/OPD/referral investigation Whether 24 hours or not Centralised labs usually are better due to ability for better quality control De-centralised laboratories will be essential for medical colleges or bigger hospitals as all labs can not be accommodated centrally due space constraints Availability of skilled manpower Number of tests expected to be conducted per technician per annum Reception, report delivery systems and Billing counters Room for doctors reproting Satellite lab requirements Satellite collection centres Material to be used for floor, walls, and work benches, should be carefully decided to avoid corrosion due to chemicals Interface of equipment with computers for online printing Role of computers in reporting ad dissipating information to other users in hospital

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Decision criteria as suggested

by Public Health Department USA

1. Determine which services are to be provided 2. Determine space requirments to accommodate equipment and personnel in the following areas: a) Administrative b) Technical c) Auxiliary ( includes washi ng, sterilizing, storage and locker facilities) 3. Divide the technical area into functional units such as Heamatology, Biochemistry, Histopathology, Microbiology, Blood Bank etc) 4. Determine where the procedures are to be performed a) Those to be combined in the same work area b) those to be done in completely separate work area 5. Estimate the volume of work in each area or unit and allow fo r future increase in workload 6. Indicate the number of personnel requiring a work station in each unit 7. Describe the major equipment in each unit: a) Indicate the linear feet of bench space required and how the space may be arranged b) Indicate equipment that requires utility lines and indicate the location c) List equipment such as refrigerators, centrifuges, desks that may be jointly used by technologists from different work stations 8. Indicate the desirable functional arrangements (example microbiology may be located at the extreme end to avoid contamination hazard and the washing area should be next to units, haematology may be next to the waiting area or specimen centre) 9. Indicate which areas may need to expand. (It may be possible to locate these areas in the end of the department to facilitate efficient, co-ordinated expansion) 10. In the technical area a standard module for work area is suggested (for instance a module of 10ft X 20 ft). By using such modules the architects can plan the structural patterns more efficiently. 11. List the utilities to be provide and any special requirements for instruments such as electronic counters. Separate electrical circuits may be necessary for some electronic equipment to avoid fluctuations in voltage, which may affect the accuracy of these equipment. 12. List environmental requirements such as light, ventilation, colour, and isolation of equipment that may require special environment.

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RADIOLOGY (Department of Imaging)

X-RAY NUCLEAR MEDICINE emission radiology ULTRASOUND CAT-SCAN MRI MAMMOGRAPHY PET SCAN

One has to be very careful in planning this department as it is probably the most expensive of all departments in an hospital. It is estimated that the department may account for 40-50% of the cost of the total medical equipment.

Basic Planning Criteria: 1. 2. 3. 4. 5. Workload projections for all sub-specialities for the next 5-10 years What would be types and numbers of investigations for various patients? What would be the utilization of work space? What is the best way of locating the units to ensure supervision, maximum efficiency and convenience to patients and staff? Whether to have the department centralized or decentralised? Centralised department would be the best but may not be feasible due to high investment costs. Centralised area will require separate wait areas for IPD and OPD patients. Will always have separate facility for casualty department Mobile units and IITV requirements Consultation with BARC or any Atomic Energy authority should be consulted for specification regarding X-ray protection.

6. 7. 8.

Location & Space Requirements: Preferably on the ground floor but not necessary Accessibility as per ambulatory/escorted/vertical transport Separate block for CT/MRI due to environmental requirements Reception area/s central v/s individual Billing area for cash collection (centralized/de-centralized) Nursing station Waiting area requirements will be more due to patients coming on stretcher and wheel chairs. Also procedures may take long time. Record room (localized/central) Reporting Area (individual/common) Hand wash facility and toilet facility inside the X-ray/USG rooms Contrast media room and patient preparation room

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Storage room for films, reports etc Dark room/s where there are several x-ray rooms, a dark room in between a set of two proceudre rooms should be adopted for better speed Changing room facility in all procedure rooms Internal layout details as per the speciality. Seek details from vendors.

Relationship with other departments:

In-patient work loads and emergency calls system OPD (Digital imaging data transfer facility) Outside referrals (use of tele-medicine) Operation theatre requirements (Mobile/IITV) Medical records Admission and Billing Casualty

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OPERATION THEATRES This is the core area of any hospital as usually 50-60% of patients in any hospital are surgical. Also it is very expensive to construct and maintain the OTs. In the current trend, many surgeries have been replaced by more simpler laser, keyhole, microsurgeries, and endoscopic surgeries. In western countries it is now even possible to operate by using tele-medicine ROBOTs from far off places. There are various types of sub-specialities which have unique requirements which planners will have to bear in mind. The commoner specialities are:

Cardio-thoracic Neuro-suergery Ophtalmic and ENT surgery Orthopaedics Plastic surgery Paediatric surgery

Factors influencing Operation Theatre Complex Planning: a) b) c) d) e) f) g) h) i) j) The number of surgeons and their specialities Projection on patient load The case mix and type of operations. For planning purposes it is advisable to categorize the operations as emergency ad elective. Number of existing/proposed surgical beds ALOS of surgical patients Number of beds available or needed Average time taken for surgery including cleaning up time Emergency surgery workload and the time to be kept reserved Socio-economic trends in the service area Is the institution going to be a teaching hospital? For Indian Theatres conducting general surgeries it should be estimated that average daily number of surgeries will be 5 @ 75 minutes per operation Separate emergency OT is justified when 50 or more cases are reported in the casualty

Projection of OT Facilities: Number of operations per day = Number of surgical beds ALOS of surgical patients Total number of operations in hospital Capacity of one OT

Number of OT rooms

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Distribution of OTs; Centralized greater economy of staff & equipment better professional supervision greater efficiency De-centralized quantum of work should justify Ophtalmology, ENT, gynaecology Teaching institution requirement Separate units/depts Speciality requirements

Location:

Top floor may be good by architectural viewpoint but medically lower floors are more preferred. There would be problem of solar heating, and stack effect infection from the lower floors due to upward air-movement. It permit easy accessibility and communication from the surgical wards Should be close to vertical transport with preferable dumb waiters for CSSD

Basic Requirements in design: Clean and dirty should be segregated The department should be independent of the general traffic and movements of the rest of the hospital The roms should be arranged in a manner that allows continuous progression from entrance through the various zones that become increasingly clean. Staff within the department should be able to move from one clean area to another without having to pass through unprotected areas Dirty material should be removed from the department without passing through the clean areas The heating and ventilation systems should be safe and comfortable to both staff and patients Entrance should be so located as to discourage unauthorized entry

Circulation within the department: Patients: Wards ------------ Reception --------- Pre-op waiting -------- anaesthesia ------ Operation theatre -------- Post op area ------- ICU/Ward

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Dr. Vivek Desai

Staff: Entrance ----- Chagning rooms ------ Working area ------ Rest room/changing room ------ Exit

Equipment & Supplies: a) Clean : b) Sterile: c) Dirty : Entrance ---- Supply area --- Thetare area ---- Point of use CSSD ---- Thetare ----- Preparatio area ----- Point of use Theatre ---- Disposal Room ---- CSSD --------> Laundry

Space Requirements: 1. 2. 3. 4. 5. 6. 7. Entrance and receiving station Patient receiving and transfer area (1.5 beds per theatre) Changing rooms (12 sft per person) and toilets Rest rooms Office for OT incharge/sister Office for staff (if required) Operating room suite (for each OR) a) Scrub up and gowning area (100 sft) b) General preparation area c) Aneasthetic room for induction (not common now, if used then 150 sft) d) Operation theatre e) Exit lobby f) Disposal and cleaning area 8. Disposal corridor 9. Stores 10. Mobile X-ray room 11. Dark room (if required) 12. Pantry 13. Recovery area (1.5 beds per theatre) 14. Clean and dirty utility (80-100 sft) 15. Circulation space for the above areas 16. Plant room for OT utilities like A/c, electrical etc. (800-1000 sft)

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Dr. Vivek Desai

Planning Approaches: The guiding principle for planning an efficient theatre system is to ensure easy circulation of staff and materials. It should be insisted upon that theatre corridors should never be less than 2.85 meters wide and preferably 3.2 meters. Layout Zones: Zone I : Zone II: Zone III: consists of OR, anaesthetic room, scrub up, and preparation space stores, processing, TSSU, and sterile store reception area, transfer spaces, post-op recovery, staff changing, admins

Classification of Layouts: There are six basic layouts which have been used in modern theatre plans in western countries. 1) Single bank single corridor : ORs are arranged in a line on one side of corridor and the stores, processing sections, and change rooms etc on other side 2) Single bank double corridor : OR banks are surrounded by corridors around it with stores ad supllies on one side and patient and staff traffic on the other with separate entrances for staff and patients 3) Double bank double corridor (Type A) : In big OT complexes to decrease travelling length, the theatres are designed in two banks with double corridors on the same basis as single bank double corridor design 4) Double bank double corridor (Type B) : Here the stores and supplies arrive directly from their issue areas into the section for them which is placed between the two banks. The transport is by lifts 5) Multi bank single corridor 6) Multi bank double corridor Other considerations: Air conditioning systems temperature 21 + 2 degrees, three stage filteration with laminar air flow, progressive positive pressure concept, 50-100% fresh air, return air concept, AHU locations, Electrical wiring and sockets OT lights (60,000 to 1,00,000 Lux Halothane lights temp is only 14 degrees), ease in handling the lights during operation Telephone and communication Computers for billing and inventory Piped suction, oxygen, and nitrous oxide (pendents)

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Dr. Vivek Desai